Healthcare Provider Details

I. General information

NPI: 1164408993
Provider Name (Legal Business Name): MOHAMMAD REZA KAZEMAINI MOFRAD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 11/02/2021
Certification Date: 11/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43112 15TH ST W
LANCASTER CA
93534-6219
US

IV. Provider business mailing address

43112 15TH ST W
LANCASTER CA
93534-6219
US

V. Phone/Fax

Practice location:
  • Phone: 661-951-2826
  • Fax:
Mailing address:
  • Phone: 661-951-2826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberM9398
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License NumberA92090
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA92090
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: